Archive for August, 2009

Psychotropic Drugs — Fast Facts

Psychotropic Drugs — Fast Facts

Jerrold S. Maxmen

New York, NY: W.W. Norton and Company, 279 pp., 1991

Most psychiatrists are professional “jet-setters,” living busy professional and social lives. As a result, continuing medical education is easily sidelined by the demands on our time. Any source of information which is comprehensive, well packaged and easy to consult should be seized upon, cherished and used frequently.

This book meets these requirements. Antipsychotics, anticholinergics, antidepressants, monoamine oxidase inhibitors, lithium, anticonvulsants, antianxiety agents, hypnotics and stimulants are each summarized in a clear and tabular format. The pharmacology, clinical indications, side-effects, cost and many other useful gems of information are covered for each drug and group of drugs. The author claims this to be a BWV (book without verbs), and, although this is an exaggeration, it is nevertheless a readable and informative precis of the field.

The book’s only drawbacks are its cost and the likelihood that it will become out-dated as new products and problems emerge. However, this is compensated for by its wire-bound format and size — it (just) fits into my pocket. It can be highly recommended as a quick reference manual.

Patient Encounters

Patient Encounters

James H. Buchanan

New York, NY: Henry Holt and Company Inc., 346 pp., 1991

Medical education has been under heavy attack in recent years for the dehumanizing effect it has on students. The strong emphasis on basic biological sciences, on physical procedures and treatments and the regimented nature of much of the curriculum all combine to make the student forget the person behind the disease. Despite the stress given to social sciences, psychiatrists have not been exempt from these influences. The emphasis on diagnostic labels and the sometimes mechanistic orientation of some teachers can have a similar effect on students and residents.

This book redresses that balance. It provides a series of case histories on patients with various serious diseases. These include amyotrophic lateral sclerosis, multiple sclerosis, lupus, AIDS, cancer, depression (with suicide) and voyeurism. A brief clinical and pathological description of the disease is provided after which the full personal history of one patient is given. These are written from the patient’s perspective and the author uses his imagination, though without overstating his case, to describe what patients are experiencing.

In the main the histories are based on individuals the author himself knew and the stories they recounted to him. A personal note is introduced by the description of the illness and death of his mother from lung cancer, and his own experience of having subacute bacterial endocarditis at the age of 8.

The author is a philosopher who has been involved in medical ethics and decision making. The book reads easily and is highly recommended as an antidote to the scientism of medicine and to the structured organization of medical education.

The Philosophical Defence of Psychiatry

The Philosophical Defence of Psychiatry

Lawrie Reznek

New York, NY: Routledge, 252 pp., 1991

The goal of this book is stated at the outset. It aims “to provide psychiatry with philosophical foundations.” Not a small challenge to undertake. But the author, who trained as a psychiatrist after obtaining a doctorate in philosophy from Oxford University, appears better suited than most to attempt such a task. Dr. Reznek argues convincingly that philosophy is not simply an interesting vantage point from which to discuss psychiatry, but that it is necessary in order to understand psychiatry and the criticisms that have been levelled against it.

The reason for which a philosophical approach to psychiatry is required is explained in the introduction. The author acknowledges that “psychiatry is in a theoretical mess” and implies that this state of affairs leaves the door wide open for criticism. The introduction is appropriately short, since not much space is required to support this premise. Different psychiatrists will treat the same mental condition differently, will understand the nature of mental abnormality differently and can base their entire clinical practice on formulations and assumptions that are in direct conflict with those of their peers. Reznek writes that “as a science over two thousand years old, one expects some agreement as to the basic form of psychiatric explanation.” But the way in which one psychiatrist approaches a clinical problem will likely have more to do with what the psychiatrist believes to be true, than with what can be proven to be the case.

However, after boldly acknowledging this state of affairs, the author proposes that we may not be in quite as much of a mess as some would argue. Maybe some of the different ways of understanding mental conditions are not as fundamentally opposed as they appear at first glance. Do the various formulations — psychodynamic, behavioral, neurochemical and others — truly represent different paradigms from which explanatory theories are derived, or can they be better understood as variant theories all within a more comprehensive medical paradigm?

This is the basic argument of the author and a basis for his philosophical defence of psychiatry. That seemingly disparate explanations of mental and behavioral anomalies do not represent mutually exclusive paradigms, but rather different theories that are not intolerably in conflict with a medical paradigm. The critics of psychiatry are not really hitting at the foundation of psychiatry as a branch of medicine, but capitalizing on the plethora of theories, each with its own explanatory power, its own proponents, and in its own stage of evolution, that have been proposed within the broad boundaries of the medical paradigm.

After a first chapter, in which the medical paradigm is explained in detail and meaning, seven chapters examine the ideas of prominent persons with radically different perspectives on the nature of mental conditions. Interestingly, six of these chapters debate the arguments of some of the most prominent critics of modern psychiatric practice (Hans Eysenck, Ronald Laing, Thomas Szasz, Peter Sedgwick, Thomas Scheff, Michel Foucault), while the seventh examines the ideas of Sigmund Freud. How does the author justify lumping these people together? Each has proposed theories that contradict certain core theses of the medical paradigm, thereby raising serious questions about the place of psychiatry in medical science.

For example, Eysenck argued that behavioral disorders are, in some cases, caused by organic disease (and therefore fall into the field of neurology) and, in other cases, are not diseases at all, but result from normal processes of learning or conditioning (a subject that Eysenck says is fundamental to psychology, not medicine). Others also argue that many mental conditions are not best conceptualized as disease processes, but as understandable and intentional protective mechanisms (Laing), the result of social construction (Sedgwick) or the labelling of deviance (Scheff). Freud fits in well. He proposes that everyday mental and behavioral phenomena arise out of similar psychodynamic processes, as do neurotic and delusional conditions, thereby challenging the role of disease as a cause of abnormal behavior, unless one believes that every person has a disease called psychodynamic conflict. A ninth chapter compares these explanations of mental disorders, argues against their validity as distinct explanatory paradigms and proposes a comprehensive medical paradigm that considers abnormal biological processes as a sort of final common pathway that can occur with any of these alternative formulations and that results in the signs and symptoms of mental disorder.

The remaining five chapters — “The Nature of Mental Illness,” “Is Psychiatry a Science?” “Psychiatry and Responsibility” and “The Practice of Psychiatry” — further explore the author’s argument that psychiatry can best be understood in the field of medicine and examine a wide variety of interesting and relevant topics. Forceful arguments on these topics are highly relevant at a time when debates about compensation for stress-related disorders, patients’ rights, third-party payments for psychoanalysis and the insanity defense are in the news and on our minds daily.

The manner in which the author dissects these theories and the arguments he uses to defend psychiatry in the face of forceful criticism is as interesting as the conclusions he draws. As the title of the book indicates, the goal of this book is to defend psychiatry. In the chapters on prominent and/or alternative theories of mental disorders, the formulations are demonstrated in turn to be faulty, at least as they suggest that psychiatry does not or should not be accepted as part of the medical paradigm and medical practice. But the combination of strict logic, imaginary scenarios and absurd anecdotes demonstrates a manner of thinking much more familiar to philosophers and theoretical physicists than to medical practitioners, even psychiatrists. It takes some getting used to, and the author can be criticized for not preparing the reader better for what he or she is getting into. Unless the reader is already familiar with this style, the arguments take work to truly appreciate. Another criticism is the very similar style in which the early chapters are written. Each contains a brief description of a theory, some creative arguments, and concludes that the theory is faulty. Readers may be better to pick two or three of these chapters that interest them most and then proceed to later chapters.

This book is for any psychiatrist who questions or wishes to examine the nature of psychiatry itself. It is not a casual read, but requires effort. Many ideas are given in rapid fire. Some of the arguments should and will arouse scepticism. I find it difficult to accept that because abnormal mental phenomena are coupled integrally with abnormal biological processes in some currently undefinable and unmeasurable manner, that seemingly any theory of mental disorder can fit within the medical paradigm, albeit a somewhat remodelled one that is proposed. However, this is not a criticism of the book, only my thoughts on one of the ideas presented. In fact, a strength of Reznek’s writing is that it demands that the reader be drawn into the arguments. The reader cannot help but argue for or against the propositions. As a result, the reader may agree or disagree with the author’s arguments or be irritated or reassured by them. But the reader cannot avoid taking a stand, and this alone makes reading this book highly worthwhile.

GABAergic Synaptic Transmission: Molecular, Pharmacological, and Clinical Aspects

GABAergic Synaptic Transmission: Molecular, Pharmacological, and Clinical Aspects

Giovanni Biggio, Alessandra Concas, Erminio Costa

New York, NY: Raven Press, 496 pp, 1992

This book contains the latest findings in physiology and pharmacology on the central GABAergic transmission complex. The findings were presented during the VII Sardinian Conference on Neuroscience, held in Domus De Maria, Sardinia, in June 1991. Each of the 44 chapters were written by different authors and reflect each of the author’s writing styles.

The book begins logically with molecular biology and progresses to molecular and clinical pharmacology and therapeutic approaches. It is divided into large sections, which makes it easier for readers to choose the chapters of interest to them.

The first section discusses molecular biology and molecular pharmacology. This is a highly specialized section for those who are familiar with the molecular biology and pharmacology of the GABAa receptor sub-unit. The section shows the enormous progress that is being done in understanding basic molecular structures of the GABAa receptor. This field likely changes from month to month as new discoveries are added. Therefore, what is in the book is a snapshot of the state of the art in 1991, when the conference was presented.

The next section, “Allosteric Modulators: The Neurosteroids,” is a very technical section on the interaction between the neurosteroid and GABAa receptor functions. In addition to papers on animal studies on rats’ brains, there is an interesting chapter on the interaction between neu-rosteroids and Huntington’s disease, which has some clinical applications.

The section on GABAa/benzodiazepine receptor subclasses shows the complexity of the interaction of the GABAa receptor and benzodiazepines. There is also a chapter on the GABAA receptor. Benzodiazepines are among the most heavily prescribed drugs in the modern world. A basic knowledge of the benzodiazepine receptor would be very appropriate for clinicians prescribing this drug. This section goes down to the molecular level and shows the complexity of the regulation of GABAa receptor is. It is important because benzodiazepines have tachyphylaxis and many unwanted side-effects. This section explains from the molecular point of view what may be happening in these cases and whether there can be any benzodiazepines without undesired effects.

The last two sections which deal with two commonly used and prescribed drugs, ethanol and benzodiazepines. These are the most clinical sections of this book. They raise more questions for future research than they answer, because they show the complexity of the effects of both a simple social lubricant, such as alcohol, and heavily prescribed medications, such as benzodiazepines. There is a chapter on the preliminary results of a double-blind, placebo-controlled trial of a partial benzodiazepine agonist, which shows that there novel types of agents might be useful in clinical practice. There is also a review of drugs which are not benzodiazepines but which act as benzodiazepine receptors — the cyclopyrrolones.

In summary, this is a book to be read from cover to cover, as a novel, but rather has different information for different kinds of readers. The molecular biology and pharmacology section as well as the GABAa benzodiazepine receptor section are aimed more at the basic scientist, while the sections on ethanol and the benzodiazepines versus non-benzodiazepine GABAergic drugs are easier reading for practising clinicians.

I found this book heavy reading. However, there is a great deal of information on the state of the art of GABAergic synaptic transmission in one volume, and this, of course, makes it a required reference for all researchers and clinicians who deal with this kind of basic research and clinical research. It is not a book for people who do not have a basic understanding of synaptic transmission in general. It shows how complex the world has become as we try to understand basic mechanism of brain functioning.

Gender Disorders and the Paraphilias

Gender Disorders and the Paraphilias

William B. Arndt

Madison, CT: International Universities Press, Inc., 488 pp, 1991

This is a carefully written book which I found interesting, particularly since the history behind a variety of sexual disorders is very well summarized, including the work by Kraft-Ebbing. This is blended with current scientific research findings, providing information on both the gender disorders and the paraphilias in a single source, thereby saving a large amount of reading. The author goes beyond that, in that he covers the history and other important aspects of the sexual disorders as they relate to endocrinology, psychiatry, forensic medicine and forensic psychiatry, as well as psychology and sociology. It covers all the psychosexual disorders in terms of the DSM-III-R. I was particularly impressed with the coverage of transsexualism, transvestism, sex, gender and sexuality, which was well-summarized by Arant. In his second chapter, “Sex Gender and Sexuality,” biological sex issues were very well covered, as were issues of gender identity role. I felt that Chapter 5, “Trans-Sexual-ism,” was also very strong, dealing with the differences between transsexualism and transvestism as well as issues of sexual orientation as they affect transvestism.

The book deals with paraphilias in a similarly comprehensive fashion, with chapters on fetishism, pedophilia, exhibitionism, father-daughter incest, sadism and masochism. These chapters are full of information and are easy reading.

The author has gone to a great deal of trouble to write this book in a style that is easy to read, clear and logical, and at the same time convey considerable amounts of information. This is a book that the general psychiatrist should read, particularly in this era when it is important to be aware of psychosexual disorders and their consequences. If there was weak point to this book, I would say that the treatment of the paraphilias was dealt with lightly, but if one looks at the overall context of the book, this is most likely appropriate, given the author’s approach.

This book is a worthwhile addition to the general psychiatrist’s library as a reference text for dealing with psychosexual disorders and gender disorders.

A DSM III-R Case Book of Treatment Selection

A DSM III-R Case Book of Treatment Selection

Samuel Perry, Alan Francis, John Clarkin

New York, NY: Brunner/ Mazel Publishers, 416 pp., 1990

In the introduction to this book John Talbot states “as the science of psychiatry progresses at such a rapid pace it is apparent that its art must advance just as quickly. With every development, the selection of the most perfect treatment becomes more complex but also more critical.”

Talbot goes on to state “too often patients receive the treatment known best to, or practised primarily by the first person they consult, rather then that from which they might best benefit.” These ideas resonate very much with the concerns of many academic psychiatrists in North America.

The authors of this book have attempted to offer some guidelines for appropriate and yet critical treatment selection. They have written a fine introductory chapter in which they describe how treatment needs to be planned, they also indicate their biases. Some of these biases are that treatment decisions are not based on disgnosis alone, but in order for patients to receive the best and most effective treatment their past history, life style, current situation and interaction with the therapist must be considered in order to provide properly individually tailored treatment.

They indicate that there are somewhere between 130-200 treatments available in psychiatry, and that perhaps psychiatrists can be categorized in three groups: specialists, eclectics and sceptics who believe that non-specific factors are most important. The authors examine the setting, format, time, approach, and the question of somatic treatments or no treatment as entering into all treatment decisions.

They state that the process of treatment selection is truly a matter that academic psychiatrists must examine more carefully. For instance people can decide on a medical model entirely. The authors state this is too simple. They state that diagnosis has been shown to have only slight correlation with treatment selection and outcome and give a reference in the Archives of General Psychiatry to back up this statement.

A preferable method of selecting treatments is to consider other aspects of the patient in addition to treatment. One must train our students and all mental health professionals to consider the presenting problem, character traits, premorbid personality, motivation, psychological-mindedness, socio-economic status, family situations and ego strength. The authors point out that patients have expectations of treatment and that this influences outcome. This finding has been shown in many trials particularly in the area of depression.

And finally as we might expect, the cases which are outlined in all DSM III-R categories are rich and exciting to read. Furthermore, cases under mood disorders, anxiety disorders and adjustment disorders provide the most provocative and interesting discussions as to why various forms of psychotherapy or pharmacotherapy or a combination of these modalities have been chosen. It has always been my view that these are the most exciting areas in psychiatry because they lead to bias in treatment selection and should, in sophisticated academic centers, lead to an opportunity to further our knowledge by enlightened and constructive intellectual debate.

The Mental Health Professional and the Legal System

The Mental Health Professional and the Legal System

Committee on Psychiatry and the Law, Group for the Advancement of Psychiatry

New York, NY: Brunner/Mazel Publishers, 208 pp, 1991

This is an excellent book which was formulated by the Committee of Psychiatry and the Law of the Group for the Advancement of Psychiatry. Since the members of this committee are some of the top forensic psychiatrists in the US, there is no question about the quality of this book. From the first chapter, an overview entitled “You and the Law,” to “Law and the Legal Process,” the “Need for Mental Health Professionals in the Legal System,” “Common Legal Tests,” “The Therapist in Court,” “Legal Issues Arising in the Treatment Relationship,” “Civil Commitment,” “Legal Requests and Subpoenas,” through a whole area of examination, experts reports and court testimony, this is a book of high quality which guides the reader through different areas as concisely and appropriately and in as clear a format as I have seen. Although this book is geared towards the American legal system, there are references to English Common Law in the introductory chapters, as well as a basic chapter that follows the course of a criminal trial which applies in both Canada and the US.

Similarly, the outline for the course of a civil trial also applies to Canada. The basic structure of the US court system is obviously different, although there are similarities to the Canadian system. When, however, it comes to the chapters on the mental health professional’s interaction with the legal system in the areas of competence to stand trial, insanity defence, pre-sentence hearings, capital sentencing, extreme emotional disturbance, competence to be executed, competence to be a witness and sex offenses committed by mentally disordered individuals and corresponding areas of civil law, the principles outlined in the book need only minor modifications to apply in Canada. These are landmark cases in the US which are not directly applicable in Canada, although legal history has shown that decisions made in the US can influence to some degree subsequent decisions in Canada.

This book covers the basic principles of law and psychiatry and the mental health professions with clarity and precision. I strongly recommend this book for general psychiatrists who have an interest in psychiatry and the law, and particularly for those in the US. It would be an excellent teaching tool for residents in psychiatry, offering basic knowledge and understanding of the legal system and how it interacts with psychiatry. For Canadian readers, it is a useful reference book, and, as already outlined, supplies sufficient basic information, although what would is needed is an identical book dealing entirely with Canadian issues.

In summary, this is a well-priced, well-written book, excellent value for the money, and a worthwhile addition to anyone’s library. I have no hesitation in recommending it.

Clinical Brain Imaging: Principles and Applications

Clinical Brain Imaging: Principles and Applications

John C. Mazziotta, Ph.D., Sid Gilman

Philadelphia, PA: F.A. Davis Company, 480 pp, 1992

This is a book for the lean and mean 90s. Once mighty medicine must now genuflect before the mightier bean counter. Rationalization of medical resources is the buzz word. And so it goes with neuroimaging, whose expensive technology demands appropriate use.

This book correlates four methods of neuroimaging: x-ray computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) and single photon emission computed tomography (SPECT). Ultrasound is inexplicably excluded, even though it is computer-based and cross-sectional and well-established for neonatal neuroimaging.

The book is methodical and would serve well as a text for a graduate course in neuroscience. The first four chapters tackle the basic principles, i.e., physics, physiology and pharmacology of CT, MRI, PET and SPECT. Although these chapters are simplified from a physicist’s perspective, others will find them tough going. A resident in neurosurgery who is deprived of sleep is not likely to wade through them. This is a shame, since the chapters establish a firm foundation for the rest of the book.

The remaining chapters deal with the clinical aspects of neuroimaging, attempting to cover such broad subjects as neoplasms, cerebral vascular disease, movement disorders and dementia. Here the book excels, highlighting the indications and limitations of each method of imaging. Flow charts are often included, guiding the reader through the most appropriate use of each technique to arrive at a proper diagnosis.

All this technology is still evolving and is outpacing the typesetter. Despite the epilogue entitled “Future Visions,” the book is already becoming dated. The exciting MRI developments of magnetization transfer contrast and relative cerebral blood flow imaging are not mentioned at all.

In summary, this is a well conceived and executed book which I recommend to anyone involved in the neurosciences, particularly those on the clinical side who are trying to cope with the multitude of imaging techniques now available.

The Art of Psychotherapy

The Art of Psychotherapy, Second Edition

Anthony Storr

New York, NY: Routledge, 208 pp, 1990

In the first edition of The Art of Psychotherapy, published in 1980, the renowned psychiatrist, psychotherapist and author Dr. Anthony Storr tackled the monumental task of writing a truly introductory book about dynamic psychotherapy that is both accessible and understandable. He succeeded at that task admirably and ten years later has published a second edition which is just as effective an introduction. The second edition has an updated section on the obsessional patient and an added chapter outlining some of the ideas that he explored in Solitude, published in 1988. As always, Dr. Storr’s writing is readable, easy to understand and thoughtful.

Most writing in the field of dynamic psychotherapy can be inaccessible to those struggling to come to grips with the field because of language and terminology that is highly technical and often largely theory-bound. Although this type of writing allows for precision, it can also frustrate the new psychotherapist, who is already facing the anxiety of learning a very new and different way of working with patients.

Dr. Storr is able, in his book, to strip away almost all the theory-bound concepts and terminology that create confusion and still preserve the core ideas that underlie the work and art of dynamic psychotherapy. His ideas are clearly formulated and presented, divorced as much as possible from theory without losing their strength.

Other writers, in attempting introductions to this field, have used the approach of sticking to one theoretical model in an attempt to simplify the issues. However, this can create dogmatism as a defence against the anxiety of not knowing “the answers.” Storr’s approach instead is to introduce the core ideas and introduce the idea that there is uncertainty in any attempt to understand people, encouraging an openness to question that parallels the therapeutic stance in psychotherapy. Indeed, in this book he attacks the rigid adherence to one psychotherapeutic school several times, a practice he predicted would fade even in his first edition, which was written over ten years ago.

Unfortunately, the one weakness of the book as an introductory text is closely if not inextricably bound to its very strength. His avoidance of technical terminology, particularly as it pertains to diagnostic systems in vogue, will create some barriers in the task of introducing psychotherapy to people who are new to the field. With no attempt to integrate the ideas expressed in the DSM or ICD diagnostic systems, which new therapists will already know, the book may reinforce the apparent artificial dichotomy between these areas of psychotherapy and biological psychiatry. It can be useful to move away from these diagnostic systems at times in psychotherapy to enhance the understanding of individuals, but may also create resistance and misunderstanding in some readers new to this area. In part because of this lack of integration, references to the pharma-cotherapy of depressed patients infer that such treatment is generally incomplete and may be harmful in the long run, not allowing for complete resolution of the underlying depressive ideas. This may create unnecessary resistance to his other ideas and may reinforce the apparent dichotomy between biological and dynamic psychiatry.

This book is nonetheless excellent and one of the best books to introduce mental health professionals to the field of dynamic psychotherapy. It could well form the core of an introductory text in this area. Its tendency to avoid overreliance on theory, and Dr. Storr’s brilliant distillation of the core concepts of psychotherapy are quite unmatched now as they were unique ten years ago.

Understanding and Treating Mental Illness

Understanding and Treating Mental Illness

John M. Cleghorn, M.D., Betty Lou Lee

Toronto: Hogrefe & Huber Publishers, 237 pp., 1991

This book emerges from the work of the Scientific Council of the Canadian Psychiatric Association, chaired by Dr. John Cleghorn, who with Betty Lou Lee has edited this excellent book.

The book is sub-titled “Understanding and Treating Mental Illness”; it is written to give an understanding of mental illness to those suffering from mental illness and for those interested members of the general public. It will be of particular value to the families of people who are unfortunate enough to have a member who is mentally ill.

Although, the book is a product of a committee, it has been superbly edited; it is very readable, indeed, I found it a pleasure to read.

It reviews all the major categories of mental illness, including chapters on personality disorders, addictions, Aids, sexual abuse, etc. After general discussion of each disorder it looks at causes, various treatment approaches, recent research where applicable, and ends with references to further information sources, including addresses of organizations associated with a specific condition.

This book should be read by all people involved with mental illness, and mental health in its broadest sense. It should be available in all hospitals, clinics and libraries.

I thoroughly enjoyed reading it, found it easy to read and sincerely hope that it will receive wide distribution. A book of this nature, which explains the strengths and limits of modern psychiatry, has long been needed.